A recent study highlighted discrepancies between qualitative client self-reports of outcome and OQ-45 reports. Specifically, only 8.8% of clients who deteriorated during a course of therapy based on the OQ-45 perceived that they had deteriorated, while 50% of these clients perceived that they had improved in therapy (Top et al., 2018). This phenomenon, where different means of tracking outcomes yield divergent results, has been called “paradoxical outcome.” The trend suggests that the most advanced forms of tracking psychotherapy outcomes might not detect important facets of outcome from the perspective of psychotherapy clients. The current study is a qualitative investigation of the experience of psychotherapy clients who reported improvements in therapy despite meeting criteria for deterioration per the Outcome Questionnaire-45.2 (OQ-45; Lambert et al., 1996). We used a consensual qualitative research (CQR) protocol (Hill, 2012). CQR uses group consensus to detect themes in participant interviews. Common themes included attributing negative changes to factors outside of therapy, endorsing complicated circumstances, and reporting positive outcomes that were not well detected by the OQ-45. More results and their implications are discussed.

Purpose: The purpose of this pilot study was to describe situation awareness (SA) among licensed practical nurses (LPNs) working in direct patient care. Specific Aims: The specific aims for this study are 1) to examine SA scores, as measured by the Situation Awareness Global Assessment Technique (SAGAT), in LPNs working in direct patient care and compare to published data on SA in registered nurses (RNs), 2) to examine the relationship between SA scores and years of LPN experience, 3) to examine differences in SA scores by type of workplace setting and 4) to describe the relationship between levels of satisfaction with simulation, as measured by the Satisfaction with Simulation Experience Scale (SSES) and SA scores among LPNs. Framework: Situation Awareness Theory, as described by Endsley, was used as the framework for this study. Design: A cross-sectional, descriptive design using the Situation Awareness Global Assessment Technique was used to gather data from a convenience sample of LPNs. Results: LPNs (N=24) participated in the study and achieved an average SAGAT score of 72.6%. There were no differences in scores between those LPNs enrolled in an RN program and those who were not enrolled. Individual scores on the SAGAT were comparable or better than scores in a similar study of RNs. Conclusion: LPNs in this study demonstrated adequate situation awareness. Key Words: Situation awareness, licensed practical nurse, patient deterioration, clinical simulation

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第19573号 / 医博第4080号 / 新制||医||1013(附属図書館) / 32609 / 京都大学大学院医学研究科医学専攻 / (主査)教授 伊達 洋至, 教授 小池 薫, 教授 瀬原 淳子 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Due to the recent advancement in computer capability, numerical modelling starts to play an important role in making predictions and improving the understanding of physics in the studies of convective heat transfer to supercritical fluids. Many computational studies have been carried out in recent years to assess the ability of different turbulence models in reproducing the experimental data. The performance of these turbulence models varied significantly in predicting the heat transfer at supercritical pressures, especially for the phenomena of heat transfer deterioration (HTD). The results of these studies showed that the accuracy of different turbulence models was also dependent on the flow conditions. It is still necessary to test these turbulence models against newly available experimental data before the final conclusion can be drawn. In this work computational simulations on convective heat transfer of carbon dioxide (CO2) and water (H2O) at supercritical pressures flowing upward in vertical circular pipes have been carried out using the commercial code STAR-CCM+. Detailed comparisons are made between five turbulence models, including AKN low-Reynolds model by Abe et al. (AKN), Standard low-Reynolds k-ε model by Lien et al. (SLR), k-ω model by Wilcox (WI), SST k-ω model by Menter (SST), and the Reynolds Stress Transport (RST) model, against two independent experiments, i.e., water data by Watts (1980) and the recently published carbon dioxide data by Zahlan (2013). The performance of k-ε models with a two-layer approach, and that of k-ε models with wall-functions are also investigated. For the CO2 study, where wall temperatures in most cases are above the pseudo-critical temperature (Tpc), RST model is found both qualitatively and quantitatively better than other turbulence models in predicting the wall temperatures when HTD occurs. The RST model while superior, predicted HTD at higher heat fluxes as compared to experiments. The wall temperature trends predicted by SST and WI models are very similar to that predicted by RST, except that they start to predict HTD at even higher heat fluxes than RST, and the peak temperatures are overestimated significantly. Because RST and k-ω models (SST and WI) predict the HTD at higher heat fluxes as compared to experiments, often in literature they are overlooked. Rather CFD users should conduct sensitivity analyses on heat flux, and quite often as a result qualitatively excellent agreement can be observed in some of these models. The low-Reynolds turbulence models, i.e., SLR and AKN, tended to over-predict the wall temperature after the onset of first temperature peak, because the turbulence production predicted by these models failed to regenerate. The wall temperatures for these models did not show recovery after deterioration until the bulk temperature is close to Tpc, while experimentally recovery happened well upstream of this location. The k-ε models with two-layer approach, and the k-ε models with wall-functions both failed to predict the HTD in all cases. For the H2O study, where the wall temperatures in most cases are below the pseudo-critical temperature, the SLR model performed the best among all turbulence models in reproducing the experimental data. AKN model was also able to qualitatively predict the observed HTD, however, not as well as SLR. SST and RST models, on the other hand, under-predicted the buoyancy effect even at the lowest mass fluxes and hence did not adequately predict deterioration. In a few high-heat-flux cases with wall temperatures above Tpc, all the turbulence models show consistent response to that discussed in the CO2 study, i.e. RST model is quantitatively better than other turbulence models. Nevertheless, the wall temperature peaks predicted by RST model is very different from that observed experimentally, i.e. the measured peaks are much milder and more flattened than the predicted ones. All the turbulence models including RST overestimate the wall temperatures significantly when Tb<Tpc<Tw. The sensitivity studies of mesh parameters, user-defined fluid properties, turbulent Prandtl number, gravitational orientation, and various boundary conditions (e.g. heat flux, mass flux, pressure, and inlet temperature) have also been carried out, aiming to ensure the reliability of the obtained results, and to gain a deeper insight into the physics of heat transfer deterioration in supercritical fluids. Detailed mechanistic studies of HTD have been carried out for both the CO2 and H2O simulations using different turbulence models (RST, SST, and SLR) in various flow conditions. The radial distribution of fluid properties and turbulence at various axial locations provides direct evidence of the mechanisms involved near the locations of deterioration. The buoyancy effect is found to be responsible for the observed HTD in both experiments (i.e., when gravity forces are removed no deterioration is observed). The buoyancy force exerted on the near-wall low-density layer modifies the velocity profile (thus shear stress distribution) in a way that greatly reduces the near-wall turbulence production, resulting in the impairment of heat transfer. In the CO2 study where the wall temperature exceeds the Tpc in a very short distance from the inlet, the “entrance effect” is found to play a more important role in initially impairing the turbulence production. However, this effect is not observed in cases where wall temperature is below Tpc, which is attributed to the weaker density variation below Tpc. / Thesis / Master of Applied Science (MASc)

Research investigating clinical versus actuarial prediction and judgment has consistently demonstrated the superiority of actuarial (statistical) methods. Little research to date has directly compared clinical and actuarial predictions in the context of patient-focused psychotherapy outcomes. The most relevant study on this issue was completed with an adult population and results indicated that the actuarial method was significantly more accurate at predicting client treatment failure compared to clinician’s predictions. This study examined clinical versus actuarial prediction of client deterioration in a sample of children and adolescents receiving treatment in a managed care and community mental health setting. Predictions of treatment failure made by the actuarial method were found to be significantly more accurate than predictions of treatment failure made by clinicians. More specifically, participating clinicians did not make a single prediction of treatment failure. These findings add further evidence to support the use of actuarial methods in enhancing clinical decision-making in community-based mental health services for children and adolescents.

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La mayoría de las impurezas y material insaponificable presente en los aceites crudos de origen vegetal es eliminada en los procesos de refinado, durante la elaboración de los aceites comestibles. La desodorización constituye la última etapa del proceso de refinado y tiene como objetivo la eliminación de los ácidos grasos libres y de sabores y olores que le confieren características indeseables al producto desde el punto de vista organoléptico (como cetonas, aldehídos, compuestos oxidados e hidrocarburos no saturados) mediante un proceso de destilación y arrastre con vapor a alto vacío y altas temperaturas. Durante esta etapa, también se eliminan parcialmente otros componentes importantes de los aceites, como tocoferoles, tocotrienoles, esteroles y ésteres grasos. Además, pueden formarse isómeros trans de los ácidos grasos y originarse pérdidas de triglicéridos por arrastre o degradación térmica e hidrolítica. Para poder analizar los procesos de desodorizado, optimizar sus condiciones operativas y/o aumentar la calidad y valor agregado de sus productos y subproductos, es necesario contar con información completa de las corrientes y con modelos adecuados de simulación para las unidades de proceso. Actualmente no existen modelos operativos completos que permitan caracterizar y evaluar el rendimiento de los sistemas de desodorización, limitándose las herramientas disponibles a algunas ecuaciones simplificadas. El objetivo general de este trabajo es el estudio teórico y experimental del proceso de desodorización de aceites vegetales por arrastre con vapor. Los objetivos específicos son: a) El desarrollo y resolución de modelos para la simulación del proceso en sus formas batch y continua; y b) El estudio del efecto de las características del material y las variables operativas sobre el deterioro del aceite y la recuperación del destilado, como fuente de tocoferoles y de otros productos de alto valor agregado. A continuación se detalla la organización del trabajo realizado. En cada uno de los capítulos se describen resultados, conclusiones y bibliografía consultada. En el Capítulo 1 se realiza una descripción de la naturaleza del proceso de desodorización y de los tipos de operación de los distintos desodorizadores, como así también de algunos equipos utilizados en la industria. En forma genérica se describe el modelado del proceso presentado en bibliografía, basado en las ecuaciones elementales de equilibrio y balances de masa. En el Capítulo 2 se describe la composición de los principales compuestos presentes en los distintos aceites vegetales así como también sus propiedades junto con las del vapor de agua. Se detallan los principales cambios ocurridos en el aceite durante el proceso. Finalmente se realiza la descripción del modelo UNIFAC utilizado para determinar coeficientes de actividad de los ácidos grasos libres, mono- y diglicéridos. En el Capítulo 3 se presenta el trabajo experimental realizado para determinar coeficientes de actividad del α-tocoferol a dilución infinita por cromatografía gaslíquido (de distintos solventes y distintos solutos). Luego a partir de los valores experimentalmente obtenidos se modela la dependencia con la temperatura del coeficiente de actividad del α-tocoferol infinitamente diluido en el aceite, utilizando el modelo UNIFAC (ampliando la base de datos con los nuevos parámetros determinados para este compuesto). En el Capítulo 4 se describe la metodología experimental utilizada para determinar la formación de isómeros trans del ácido linoleico en función de la temperatura y tiempo de exposición del aceite. También se estudió el cambio de acidez durante el proceso de desodorización, debido al efecto de la temperatura, el tiempo de operación y el vapor de agua utilizado como arrastre en el proceso. Se discuten los resultados obtenidos y se modelan las cinéticas determinando el orden y las constantes para ambos modelos. Luego se comparan los resultados con cinéticas encontradas en la bibliografía para la generación de trans isómeros. En el Capítulo 5 se detalla el modelo matemático desarrollado para la desodorización batch, en el que se considera un proceso de arrastre con reacción química. El aceite es representado por los triglicéridos, considerado no volátil y como compuestos volátiles los cinco ácidos grasos libres principales (palmítico, esteárico, oleico, linoleico y linolénico), un mono- y un diglicérido representativos, y el α-tocoferol. A partir de la simulación se analiza el efecto de la composición del aceite y de las distintas variables del proceso. En el Capítulo 6 se expone el modelo matemático para la desodorización continua, el que consiste principalmente en un conjunto de ecuaciones algebraicas que representan la eliminación por destilación o arrastre con vapor de los distintos componentes del aceite. Para determinar la eficiencia del proceso se utiliza el método AIChE, el cual predice la eficiencia de Murphree para platos con campanas de burbujeo. La simulación permite evaluar la influencia de las variables operativas en la calidad y composición final del aceite y del destilado. Finalmente, en el Capítulo 7 se resumen las conclusiones generales de la tesis y se proponen trabajos a futuro sobre el tema de investigación. / Most of the unsaponifiable material and impurities present in crude vegetable oils are removed in the refining processes, during the production of edible oils. The deodorization is the last stage of the refining process and has as its objective the removal of free fatty acids and flavors and smells that render undesirable organoleptic characteristics to the product (such as ketones, aldehydes, oxidized compounds and unsaturated hydrocarbons) through a process of distillation and steam stripping at high vacuum and high temperatures. During this stage, other components of the oils, such as tocopherols, tocotrienols, sterols and fatty esters, are partially removed. Formation of trans isomers of fatty acids and loss of triglycerides, caused by entrainment and thermal or hydrolytic degradation, can also occurs during the process. To analyze the processes of deodorization, to optimize their operating conditions and/or to increase the quality of value-added products and byproducts, it is necessary to have detailed information about the process streams and simulation models for process units. There are currently no operative models to enable complete characterization and performance assessment of deodorization systems, limiting the tools available to some simplified equations. The general objective of this work is to study experimentally and theoretically the deodorization process of vegetable oils by steam stripping. The specific objectives are: a) To develop and solve mathematical models for simulating the process in their batch and continuous forms; and b) To study the effect of material characteristics and operating variables on the oil deterioration and distillate recovery, as a source of tocopherols and other natural products of high added value. The organization of the work is given below. Results, conclusions and reviewed bibliography are presented in each chapter. Chapter 1 is a description of the nature of deodorization and types of operation of the various deodorizers, as well as of some equipment used in the industry. Generically presents the process modeling used in the literature, based on elemental equilibrium equations and mass balances. Chapter 2 describes the composition of the main compounds present in vegetable oils as well as their properties along with those for water vapor. The main changes in the oil during the deodorization process are discussed. Finally presents a description of UNIFAC model used to predict activity coefficients of free fatty acids, mono- and diglycerides. Chapter 3 presents the experimental work carried out to determine activity coefficients of α-tocopherol at infinite dilution by gas-liquid chromatography (different solvents and different solutes). Then the values obtained experimentally for the coefficient of activity of α-tocopherol infinitely diluted in the oil, and its temperature dependence, are modeled by using the UNIFAC model (extending the database with the new parameters determined for this compound). Chapter 4 describes the experimental work carried out to determine the formation of trans isomers of linoleic acid as a function of temperature and exposure time of the oil. The change of acidity during the process of deodorization due to temperature, time of operation and water vapor used as a drag on the process is also studied. The results are discussed and the kinetics are modeled by determining the order and the constants of reaction for both models. The results are compared with the kinetics found in literature for the generation of trans isomers. Chapter 5 details the mathematical model developed for the batch deodorization, considered as a stripping process with chemical reaction. The oil is represented by the triglyceride, which is considered non-volatile, and volatile compounds as the five major free fatty acids (palmitic, stearic, oleic, linoleic and linolenic), representative mono- and diglycerides, and α-tocopherol. From the simulation, the effect of oil composition and process variables is analyzed. Chapter 6 sets out the model for continuous deodorization, consisting mainly of a set of algebraic equations representing the removal by distillation or steam stripping of the various components of the oil. The efficiency of the process is determined by using the AIChE method which predicts the Murphree efficiency for trays with bubbling bells. Simulation allows to evaluate the influence of operating variables on quality and final composition of the oil and the distillate. Finally, Chapter 7 summarizes the overall conclusions of the thesis and suggests future work on the research topic.

Three main objectives have been set for this research. The first is to develop an accurate method for measuring the dielectric constant of PCC using a capacitor probe (C-Probe) that has been recently developed at Virginia Tech and validate it for field application to detect internal PCC flaws such as delamination. The C-Probe consists of two flexible conducting plates, connected to a Network Analyzer, with a specific separation between them. The second is to optimize the C-Probe design configuration for different PCC slab thicknesses. The third objective is to develop a predictive model that correlates the bulk dielectric constant of PCC with its critical parameters (cement, aggregate, and air content). Five calibration methods have been developed and evaluated for the C-Probe to measure the dielectric properties of PCC. This evaluation has demonstrated that open, short, Teflon material (OSM) calibration method is the most appropriate one for the C-Probe. The selected calibration method was used to validate the C-Probe fixture for field application by measuring 1.5 x 1.5 m PCC slabs prepared with different mix properties, thicknesses, and induced deterioration. The C-Probe has been proved to detect induced voids in the PCC slabs. In addition, the effect of steel reinforcement on measurements can be mastered by controlling the penetration of electromagnetic (EM) field in the PCC slabs. The effective penetration depth of the EM field for different C-Probe design configuration was optimized by computer simulation. The results have been used to develop a predictive model that correlates the effective penetration depth with the plates' size, separation between them, and the dielectric constant of the PCC under test. Thus, an optimum design for different desired penetration depth was achieved. Two experimental designs were developed to identify the critical parameters that affect the bulk dielectric constant of PCC. A computer simulation was used to identify the significance of each parameter. A predictive model has been developed to correlate the PCC bulk dielectric constant to the critical parameters. The estimated dielectric constant of PCC using the predictive model was correlated to that obtained by other theoretical mixture models; the predictive model has found to correlate well with Looyenga theoretical mixture model. / Ph. D.